JEFFERSON PHARMACY
194-B Turkeysag Trail
Palmyra VA, 22963
(434) 589-7902
Legal Name
Preferred Name
Date of Birth
Address
Gender (as listed by your insurance)
Male
Female
Home Phone (if applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
Home
Cell
Email
example@example.com
Insurance Information - Member ID
BIN
PCN
RX Group Number
Drug Allergies and Reactions
Medical Conditions/Diagnoses
Would you like to be notified when your prescriptions are ready?
Yes, by text
Yes, by email
No
Would you prefer "Easy-Off" or "Child-Resistant" caps?
Easy-Off
Child-Resistant
Would you like all of your prescriptions to be filled at the same time if possible?
Yes
No
Would you like your applicable prescriptions to be on automatic refill?
Yes
No
Do you have medications at another pharmacy that you would like transferred to us? If so, please provide the pharmacy name and phone number, as well as the items you would like transferred.
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